CKDNET, a quality improvement project for prevention and reduction of chronic kidney disease in the Northeast Thailand.

BACKGROUND: The incidence of chronic kidney disease (CKD) is high in the Northeast Thailand compared to other parts of the country. Therefore, a broad program applying all levels of care is inevitable. This paper describes the results of the first year trial of the Chronic Kidney Disease Prevention in the Northeast Thailand (CKDNET), a quality improvement project collaboratively established to curb CKD. METHODS: We have covered general population, high risk persons and all stages of CKD patients with expansive strategies such as early screening, effective CKD registry, prevention and CKD comprehensive care models including cost effectiveness analysis. RESULTS: The preliminary results from CKD screening in general population of two rural sub-districts show that 26.8% of the screened population has CKD and 28.9% of CKD patients are of unknown etiology. We have established the CKD registry that has enlisted a total of 10.4 million individuals till date, of which 0.13 million are confirmed to have CKD. Pamphlets, posters, brochures and other media of 94 different types in the total number of 478,450 has been distributed for CKD education and awareness at the community level. A CKD guideline that suits for local situation has been formulated to deal the problem effectively and improve care. Moreover, our multidisciplinary intervention and self-management supports were effective in improving glomerular filtration rate (49.57 versus 46.23 ml/min/1.73 m2; p < 0.05), blood pressure (129.6/76.1 versus 135.8/83.6 mmHg) and quality of life of CKD patients included in the program compared to those of the patients under conventional care. The cost effectiveness analysis revealed that lifetime cost for the comprehensive health services under the CKDNET program was 486,898 Baht compared to that of the usual care of 479,386 Baht, resulting in an incremental-cost effectiveness ratio of 18,702 Baht per quality-adjusted life years gained. CONCLUSION: CKDNET, a quality improvement project of the holistic approach is currently applying to the population in the Northeast Thailand which will facilitate curtailing of CKD burden in the region.

Budget impact analysis of the new reimbursement policy for day surgery in Thailand.

INTRODUCTION: In 2017 the Thai Ministry of Public Health proposed a new financing mechanism to promote day surgery under the Universal Coverage Scheme - the main public insurance arrangement for Thais. The key feature of the policy is health facilities performing day surgery can claim the treatment expense based on relative weight (RW) instead of adjusted RW (adjRW). Procedures for 12 diseases (so-called "candidate procedures") are eligible for the new reimbursement. The objective of this study was to assess the current day surgery situation in Thailand and analyze potential budget impact from the new policy. METHODS: A quantitative cross-section design was employed. Individual inpatient records of the Universal Coverage Scheme during 2014-2016 were analyzed. Descriptive statistics and simulation analyses were applied. The analyses were divided into three subtopics: 1) case volume and expense claim, 2) utilization across facilities, and 3) case mix index and budget impact. RESULTS: Overall, day surgery accounted for 4.8% of admissions with candidate procedures. Inguinal hernias, hemorrhoids, and common bile duct stones caused the largest sum of admission numbers and admission days. Currently, the annual reimbursement for candidate procedures treated as inpatient cases is around 290.8 million Baht (US$ 8.8 million), with about 12.4 million Baht (US$ 0.38 million) for day surgery cases. If all candidate procedures were performed as day surgery and diagnostic-related groups (DRG) version 6 was applied, the incremental budget would amount to 1.9 million Baht (US$ 58,903). CONCLUSIONS: The new reimbursement policy will likely lead to minimal budget burden. Even in the case of maximal uptake of the policy, the needed budget would increase by just 15%. The marginal budget increment was explained by the infinitesimal RW-adjRW difference. Apart from the financial measure, other qualitative aspects of the policy, such as infrastructure and health staff readiness, should be explored.

Association Between a Centrally Reimbursed Fee Schedule Policy and Access to Cataract Surgery in the Universal Coverage Scheme in Thailand.

Importance: Uptake of cataract surgery in developing countries is much lower than that in developed countries. Cataract unawareness and financial barriers have been cited as the main causes. Under the Universal Coverage Scheme (UCS), Thailand introduced a central reimbursement (CR) system for cataract surgery. It is unknown if this financial arrangement could incentivize service provision (private or public) in areas that are hard to reach. Objective: To examine the association between the CR policy and access to cataract surgery in Thailand. Design, Setting, and Participants: Using time series analysis, hospitalization data during 2005 to 2015 for UCS members were analyzed for time trends and subnational variations in the cataract surgery rate (CSR) before and after the CR implementation. Main Outcomes and Measures: The annual growth in access was estimated using segmented regression. The CSR gap across regions was determined by the slope index of inequality (SII). Unequal access across districts was represented by the gap between the top and bottom quintiles. Results: During 2005 to 2015, a total of 0.98 million UCS members (mean [SD] age, 67.4 [11.2] years; 58.7% female) received cataract surgery. The number of cases increased from 77 897 in 2005 to 192 290 in 2015. At the national level, the CSR per 100 000 population increased from 352.0 to 378.7 cases in 2005 to 2008, to 716.3 cases in 2013, and then to 765.3 cases in 2015. With the use of mobile services through an exclusive CR, 3 private hospitals took the lead in service growth, sharing 79.2% of cases in the private sector in 2009. From 2010, the number of cases in public hospitals grew yearly by 12.6% to 13.6% until 2012, rose 21.7% in 2013, and then the rate of increase declined to that of 8.2% to 8.3% in 2014-2015. During the periods of an increase in overall access, the CSR gap across regions widened as indicated by the SII of 755.4 cases per 100 000 population in 2010 because of rapid uptake in areas with mobile services. When the national CSR became adequately large and mobile services were discouraged in 2013, the gap in 2014-2015 narrowed. Conclusions and Relevance: This study found that the appropriate payment and service designs helped reduce the cataract surgery backlog. With an adequately high CSR, Thailand is on track to reach the VISION 2020 goal, aiming for blindness elimination by the year 2020, which has been achieved by most developed countries.

Cost-effectiveness analysis of policy options on first-line treatments for advanced, non-small cell lung cancer in Thailand.

OBJECTIVES: Tyrosine kinase inhibitors (TKIs) have shown to be better for progression-free survival than chemotherapy as the first-line treatment for advanced, non-small cell lung cancer (NSCLC), especially in patients with epidermal growth factor receptor mutation (EGFR M+). This study evaluates under the Thai health system context, cost-effectiveness of (A) the use of platinum doublets for all without EGFR testing, and (B) an EGFR test followed by TKIs or platinum doublets conditional on test results. MATERIALS AND METHODS: A decision analysis model was constructed to estimate quality-adjusted life years (QALYs) and total cost for each option. Cancer progression and death were pooled from randomized, controlled trials. Quality of life was obtained from patient interview, using the European Quality-of-Life, 5-Dimension questionnaire. Costs associated with treatment outcomes were derived from patient chart reviews. RESULTS: Combining the EGFR test with each TKI, gefitinib, erlotinib and afatinib if M+ or otherwise platinum doublets, resulted in higher effectiveness than the use of platinum doublets for all by 0.15, 0.19 and 0.21 QALYs, respectively. Among the three TKIs, gefitinib was dominated economically by erlotinib, which incurred an incremental cost-effectiveness ratio (ICER) of $46,783/QALY over the platinum doublets for all. Moving to the next best, afatinib resulted in the ICER of $198,961/QALY over erlotinib. Probabilities for any TKIs being cost-effective when compared with platinum doublets over a wide range of willingness to pay were modest. CONCLUSION: In Thailand, the first-line treatment for advanced NSCLC with TKIs conditional on EGFR test results was not cost-effective as compared with platinum doublets for all.

Cost-Utility of Video-Electroencephalography Monitoring Followed by Surgery in Adults with Drug-Resistant Focal Epilepsy in Thailand.

OBJECTIVES: This study assessed whether video-electroencephalography (VEEG) monitoring followed by surgery was cost-effective in adult patients with drug-resistant focal epilepsy under Thai health care context, as compared with continued medical treatment without VEEG. METHODS: The total cost (in Thai Baht, THB) and effectiveness (in quality-adjusted life years, QALYs) were estimated over a lifetime horizon, using a decision tree and a Markov model. Data on short-term surgical outcomes, direct health care costs, and utilities were collected from Thai patients in a specialized hospital. Long-term outcomes and relative effectiveness of the surgery over medical treatment were derived, using systematic reviews of published literature. RESULTS: Seizure-free rates at years 1 and 2 after surgery were 79.4% and 77.8%, respectively. Costs of VEEG and surgery plus 1-year follow-up care were 216,782 THB, of which the VEEG and other necessary investigations were the main cost drivers (42.8%). On the basis of societal perspective, the total cost over a 40-year horizon accrued to 1,168,679 THB for the VEEG option, 64,939 THB higher than that for no VEEG. The VEEG option contributed to an additional 1.50 QALYs over no VEEG, resulting in an incremental cost-effectiveness ratio of 43,251 THB (USD 1236) per 1 QALY gained. Changes in key parameters had a minimal impact on the incremental cost-effectiveness ratio. Accounting for uncertainty, there was an 84% probability that the VEEG option was cost-effective on the basis of Thailand's cost-effective threshold of 160,000 THB/QALY. CONCLUSIONS: For patients with drug-resistant epilepsy, VEEG monitoring followed by epilepsy surgery was cost-effective in Thailand. Therefore it should be recommended for health insurance coverage.

Constructing a state-transition model for an economic evaluation of cancer treatments.

The paper gives an overview of the four fundamental elements that should be considered when constructing a Markov model of cancers, including outcome measures, health state transition, transitional probabilities, and model calibration. The construction of any model of this kind should begin by establishing transition to the death state. The probability of this transition can be estimated using overall survival data from clinical studies. Possible health states over a cycle are defined according to the natural history of diseases and treatment pathways. Validity of the constructed model is tested against real patient data and the parameters are adjusted until the survival results are consistent.

Health insurance system and healthcare provision: nationwide hospital admission data 2010.

BACKGROUND: The three major health insurance systems are different in their medical service coverage, reimbursement process and choice of providers; leading to the question of how great are the variations in the healthcare offered and disease outcomes. OBJECTIVE: To assess whether differences exist and to analyze the effects of on healthcare provision and disease outcomes in the adult population across the three health insurance systems. MATERIAL AND METHOD: The authors analyzed the disease outcomes of the 23 major ICD-10 disease groups among the three major health insurance systems to obtain the death rates, levels of healthcare provision and the hospital charges. Factors influencing mortality rates were evaluated by multiple logistic regression analysis. RESULTS: The community, general, tertiary care and private hospitals provided hospitalization for 41.4%, 22%, 27.3% and 9.3% of hospitalized adult patients, respectively. Infectious & parasitic diseases were the most common causes of admissions. Disease of the digestive system was the most common cause of admission in general hospitals while malignancy was the most common in the tertiary care hospitals. Patients with congenital malformation, neoplasm, mental and behavioral disorder and diseases of the eye were commonly treated at tertiary care hospitals. The mean and median of hospital charges were highest in the Civil Servant Medical Benefit System (CSMBS) (26,668; 10,209 Baht), followed by the Social Security System (SSS) (21,455; 9,713 Baht) and the Universal Coverage System (UC) (13,086; 5,246 Baht). The respective overall mortality rates for the CSMBS, SSS and UC were 4.40%, 1.38% and 3.32%. After adjustment, however a significant association between UC and mortality was found with an odds ratio of 1.43 (1.40-1.45) as compared to CSMBS. In addition, other factors most influencing mortality rates were male sex, elderly age, and the levels of healthcare. CONCLUSION: The differences in charges for some groups of diseases and significantly different clinical outcomes across schemes existed. The differences in disease outcomes were not adjusted for socioeconomic status and disease severity, requiring a cautious interpretation; nevertheless, an association with a higher mortality rate under the UC scheme for inpatient services need prompt further study

Pain and quality of life of cancer patients: a multi-center study in Thailand.

OBJECTIVE: To identify the association between Quality Of Life (QOL) and pain intensity, and the magnitude of change of pain scores that have a clinically significant impact on patients' QOL. DESIGNS: Multi-center; prospective cohort study. MATERIAL AND METHOD: Patients suffering from cancer pain were recruited from seven university hospitals and three tertiary care centers in Thailand. The FACT-G and the Brief Pain Inventory were used to assess QOL and cancer pain severity, respectively, at study entry and at two-week follow-up. RESULTS: Five-hundred-and-twenty patients were recruited with a mean age of 52. The majority (76%) reported two sites of pain with 80% being treated at either step 2 or 3 (WHO guidelines of pain management). After two weeks, the average level of maximum pain was reduced from 6.6 to 4.8 (mean difference = -1.8, p < 0.001) and the QOL was improved from 58.6 to 61.0 (mean difference = 2.4, p < 0.001). There was a high correlation between the average change of pain intensity and QOL scores (rs = -0.42, p < 0.001). The results show that changes of pain scores of at least three points (3 out of 10) were required for a minimal important difference of FACT-G scores, indicating a significant change on patients' QOL. Pain deterioration had slightly more impact on QOL than pain improvement. A 3-point pain deterioration impaired QOL 10.3 points while 3-point reduction increased QOL only 7.6 points. CONCLUSION: The present findings suggest the importance of pain management. The change of pain scores of at least three points (out of 10 points) had statistical and clinical significance to patients' QOL.